Principal Investigator
HIC #________
CONSENT AND RESEARCH AUTHORIZATION TO DONATE [SELECT ALL THAT
APPLY: TISSUE/BIOLOGICAL SPECIMEN/RESEARCH DATA] FOR FUTURE
RESEARCH PURPOSES
YALE UNIVERSITY SCHOOL OF MEDICINE
INSTRUCTIONS: THIS TEMPLATE IS DESIGNED TO PROVIDE GUIDANCE IN
THE DEVELOPMENT OF A COMPOUND CONSENT/RESEARCH AUTHORIZATION
FORM FOR PROTOCOLS WHICH AIM TO DEVELOP A REPOSITORY OF DATA
OR BIOLOGICAL SAMPLES. ITALICIZED SECTIONS IN SQUARE BRACKETS
MUST BE EDITED FOR YOUR SPECIFIC PROTOCOL. NOT ALL SECTIONS WILL
APPLY TO YOUR PROTOCOL THEREFORE DELETE THOSE WHICH DO NOT
APPLY. DELETE THIS INSTRUCTION PARAGRAPH PRIOR TO SUBMISSION TO
THE HIC.
Title:
Principal Investigator:
Funding Source:
[Tissue/Biological Specimen/Research Data] Donation
You are invited to donate your [tissue/biological specimen/research data] and related
information to be stored (banked) in a research [tissue/specimen/data] database or bank where it
can be used for future research projects The [tissue/specimen/data] collected in this bank will be
used by researchers [or specify department, section researchers] to study [specify in broad terms
what the data will be used for]:
Examples:
o neurological diseases, illnesses and conditions.
o the biology, pathology, and treatment of cancer.
o reasons why people may develop diabetes, how to help treat the disease
and ways that may prevent it.
This may help researchers in the future learn more about how to prevent, find and treat [X
disease(s)/condition(s)].
In order to decide whether or not you wish to donate your [tissue/biological specimen/research
data] for future research, you should know enough about the risks and benefits to make an
informed decision. This form gives you information about the research bank and how the
[tissue/specimen/data] may be used. Once you understand the [tissue/specimen/data] donation
and banking process, you will be asked if you wish to take part; if so, you will be asked to sign
this form.
How Your [Tissue/Specimen/Data] Gets Into the Databank
The [tissue/specimen/research data] that you have donated for this research study will be sent to
the [tissue/specimen/data] bank along with the following information about you which will be
entered into a computer (the database) that is used for [clinical/research] purposes.
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Principal Investigator
HIC #________
The following information about you will be entered into the database: [Specify the data that will
be entered. Examples: name, the date that clinical or research procedures were conducted, the
results from laboratory, x-ray, scanning or other procedures, medical record number, date of
birth, race, sex information from medical history and physical examination].
How Your [Tissue/Specimen/Data] Is Stored and Used for Future Research
The researchers who are responsible for entering and protecting your information in the database
will use your information to: [State the research purposes as noted in the first paragraph, i.e.,
studying neurological diseases].
When your specimens and information are stored, we are careful to try to protect your identity
from discovery by others. Strict security safeguards are in place to reduce the chance of misuse
or unplanned release of information.
Whenever possible, the researchers will use your information in a de-identified manner. Deidentified means that the researchers will use your information without knowing your identity. In
some cases they may use some identifying information about you for research purposes, subject
to an approval process undertaken by the Yale Human Investigation Committee (HIC). (The
HIC is an ethics committee that reviews, approves and monitors research on human subjects.) At
times the researchers will use your information with a code, instead of your name; the code
would allow results of the research to be linked back to you. [If applicable, indicate any other
entities, investigators, or institutions that may have access to the data, for what purposes, under
what types of approval, and how the data will be shared with these other entities, investigators,
or institutions: identified or de-identified.]
Your specimens will be stored for an unlimited time, and may be used to make a cell line that
will live indefinitely. Future research may look at your genes, which are the units of inheritance
that are passed down from generation to generation. Genes are responsible for many things
about you such as eye color, hair color, blood type and hundreds of other traits. Future genetic
analysis may possibly include finding out the details of how your DNA is put together, such as
whole exome or genome sequencing, or genome wide association studies( that is, looking at
genes other than those associated with a specific disease). . The materials at some point may be
injected into animals in some of the research. We expect that there will be widespread sharing of
these specimens and associated information.
Risks and Inconveniences
There are no physical risks to you for donating and storing your [tissue/specimen/data] for use in
future research studies. [If applicable state whether the subject will or will not be required to
give any more (tissue/specimen/data) than that which will be taken during (this research
study/for clinical purposes/surgery, etc.)] In the unlikely chance that your information is viewed
by someone outside the research team however, there is a risk of breach of confidentiality (see
the Confidentiality section for an explanation of how your information is protected).
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Principal Investigator
HIC #________
There is a risk that your information could be misused. The chance of this happening is very
small. We have protections in place to lower this risk. There can also be a risk in uncovering
genetic information. New health information about inherited traits that might affect you or your
blood relatives could be found during a research study. Very rarely, health or genetic
information could be misused by employers, health insurance companies, and others. There is a
federal law called the Genetic Information Nondiscrimination Act (GINA) that, in general,
makes it illegal for health insurance companies, group health plans, and most employers, except
those with fewer than 15 employees, to discriminate against you based on your genetic
information. However, it does not protect you against discrimination by companies that sell life
insurance, disability insurance, or long-term care insurance.
Benefits
Using your specimens for research will probably not help you. We do hope the research results
will help people in the future. We hope that the information we learn in future research studies
will increase our knowledge of human health and that this information will lead to better
prevention, diagnoses and treatments in the future.
Economic Considerations
You will not receive any payments for donating your [tissue/specimen/research data] into the
research data bank.
Your specimens and information will only be used for research and will not be sold. There is a
possibility that this research may lead to development of products that will be commercialized.
If this happens, there is no plan to share any financial gain with you.
Confidentiality
All identifiable information that is obtained in connection with this research study will remain
confidential. Information about you will be kept [specify security measures: Example: in a
locked, password-protected computer, not connected to the internet, in a locked cabinet, etc.].
Only the members of the research [tissue/specimen/data] bank staff and researchers who have
received the approval of the HIC to use your [tissue/specimen/data] will know your identity. [if
applicable, indicate if the information will be shared with other investigators either within Yale
or outside of Yale, and if they will have access to confidential and identifiable data.] When the
results of future research are published or discussed in conferences, no information will be
included that would reveal your identity unless your specific consent is obtained.
Research results will not be returned to you or your doctor. If research results are published,
your name and other personal information will not be given.
Representatives from [indicate what agencies if any will be able to inspect the study records,
such as the NIH, or FDA] and from the HIC may inspect study records during auditing
procedures. However, these individuals are required to keep all donor information confidential.
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Principal Investigator
HIC #________
Voluntary Participation and Withdrawal
You are free to choose not to donate your [tissue/specimen/data] to research and if you do
become a donor you are free to change your mind at any time, but the researchers may still use
the information collected before you changed your mind in order to complete the research that
has already started. The researchers will anonymize the [tissue/specimen/data] by removing and
destroying all identifiers and links to identifiers so that it can not be associated with you, but the
researchers will not destroy the [tissue/specimen/data].
If you choose not to allow your information/samples to be stored and used, or if you withdraw
your permission, this will not harm your relationship with the study doctors, with Yale
University or Yale-New Haven Hospital.
This form and your permission will never expire unless you change your mind and withdraw it.
To withdraw your permission to use your information, please write to [Enter name and address
of the data repository’s principal investigator] at the Yale University
_______________________________New Haven, CT 06520.
Questions
We have used some technical terms in this form. Please feel free to ask about anything you don't
understand and to consider this donation of information and/or specimens and the consent form
carefully – as long as you feel is necessary – before you make a decision.
Privacy Rights
The health-related information that we gather about you in this study is personal. The
researchers are required by law to protect the privacy of information known as protected health
information (PHI). All reasonable efforts will be made to protect the confidentiality of your PHI,
which may be shared with others to support this research, to conduct public health reporting, and
to comply with the law as required. Despite these protections, there is a possibility that
information about you could be used or disclosed in a way that it will no longer be protected.
By signing this form, you give permission for the researchers to store and use and/or disclose the
information in this research database. You have a right to refuse to sign this form. Your health
care outside the study, the payment for your health care, and your health care benefits will not be
affected if you do not sign this form. Information about you gathered during your clinical care or
during this research study [choose one or both] will not be placed into the research data bank
described in this form or used for future research if you do not sign this form. You do not give up
any of your legal rights by signing this form.
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Principal Investigator
HIC #________
Authorization
I have read (or someone has read to me) this Consent and Authorization Form to donate
[tissue/specimen/research data] for future research purposes and have decided to donate my
[tissue/specimen/data] to the [named Bank]. The general purposes of this donation, the
particulars of my involvement and possible hazards and inconveniences have been explained to
my satisfaction. By signing below, I give permission for the described uses and disclosures of
my information.
My signature also indicates that I have received a copy of this
consent/authorization form.
CHECK ONE: [THIS SECTION IS OPTIONAL]
___ No, I do not wish to donate my [tissue/specimen/research data] to the [named Bank] for
research.
___ Yes, I do wish to donate my [tissue/specimen/research data] to the [named Bank]
only for the purposes of described above.
___ Yes, I do wish to donate my [tissue/specimen/research data] that has been de-identified to
the [named Bank] for future, undefined research which must be approved by a research ethics
committee.
___ Yes, I do wish to donate my [tissue/research data] for future research, but if the aim of the
project is different than the aim of this bank, contact me first for my permission:
Tel. Number: __________________________.
______________________________________
Signature of Subject or Personal Representative
______________________________
Date
_______________________________________
Print Name of Subject or Personal Representative
_______________________________
Description of Representative’s Authority
________________________________________
Signature of Person Obtaining Consent
___________________
Date
If you have further questions about this project, you may contact the Principal Investigator,
[Enter name and Phone number]. If you would like to talk with someone other than the researchers
to discuss problems, concerns, and questions you may have concerning this research, or to
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Principal Investigator
HIC #________
discuss your rights as a research subject, you may contact the Yale Human Investigation
Committee at (203) 785-4688. If after you have signed this form you have any questions about
your privacy rights, please contact the Yale Privacy Officer at 203/432-5919
THIS FORM IS NOT VALID UNLESS THE FOLLOWING BOX
HAS BEEN COMPLETED BY THE YALE HUMAN IVESTIGATION COMMITTEE OFFICE
THIS FORM IS VALID ONLY THROUGH:_________________
HIC PROTOCOL #: ___________________
INITIALED: ____________________
THE SUBJECT OR HIS OR HER PERSONAL REPRESENTATIVE MUST BE PROVIDED
WITH A COPY OF THIS FORM AFTER IT HAS BEEN SIGNED.
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